Provider Demographics
NPI:1477717387
Name:SAN JUAN DENTAL HYGIENE LLC
Entity Type:Organization
Organization Name:SAN JUAN DENTAL HYGIENE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RDH, MGR
Authorized Official - Prefix:
Authorized Official - First Name:MADELEINE
Authorized Official - Middle Name:
Authorized Official - Last Name:BESERRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-264-9436
Mailing Address - Street 1:PO BOX 2336
Mailing Address - Street 2:
Mailing Address - City:PAGOSA SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81147-2336
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 PAGOSA STREET
Practice Address - Street 2:
Practice Address - City:PAGOSA SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81147
Practice Address - Country:US
Practice Address - Phone:970-264-9436
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-10
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty